Objective: The objective of this study was to monitor the maternal mortality ratio (MMR) in 19 general hospitals after introducing quality assurance in four states in Nigeria.

Methods: Data collection with a structured maternity record book started in 2008 in ten rural hospitals in Kano and Kaduna State. In 2011, five hospitals from Federal Capital Territory Abuja were added, whilst in 2013 four hospitals were added from Ondo State. The routine data collection was conducted by experienced midwives and supervised by obstetricians from each of the states. However, the data from all four states were collated centrally at Aminu Kano Teaching Hospital for analysis.

Results: From 2008 to 2013, 121,808 deliveries were evaluated; MMR fell from 1380 to 360/100,000 in Kaduna State, whilst for Kano State there was a gradual reduction of MMR from 2100/100,000 in 2008 to 1070/100,000 in 2011, and then it increased to 2150/100,000 in 2013. Ondo state had the lowest MMR of 180/100,000 in 2013 followed by Abuja with 240/100,000. The median cesarean section rate was 8.19%, (range 0.97–22.53%), eclampsia/preeclampsia was 4.43% (range 0–56.55%), and postpartum hemorrhage was 3.36% (range 0.81–11.4%).

Conclusions: Quality assurance in rural hospitals generates the awareness necessary to improve maternal health and lead to reduction of MMR.